Upper Respiratory Tract Infections

Neemisha Jain, R. Lodha and S.K. Kabra

Department of Pediatrics, Division of Pediatric Pulmonology, All India Institute of Medical Sciences, New Delhi, India.

Abstract. Acute respiratory infections accounts for 20-40% of outpatient and 12-35% of inpatient attendance in a general hospital. Upper respiratory tract infections including nasopharyngitis, , tonsillitis and otitis media constitute 87.5% of the total episodes of respiratory infections. The vast majority of acute upper respiratory tract infections are caused by . is caused by viruses in most circumstances and does not require antimicrobial agent unless it is complicated by acute otitis media with effusion, tonsillitis, sinusitis, and lower respiratory tract infection. Sinusitis is commonly associated with common cold. Most instances of rhinosinusitis are viral and therefore, resolve spontaneously without antimicrobiat therapy. The most common bacterial agents causing sinusitis are S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus and S. pyogenes. Amoxycillin is antibacterial of choice. The alternative drugs are cefaclor or cephalexin. The latter becomes first line if sinusitis is recurrent or chronic. Acute pharyngitis is commonly caused by viruses and does not need . About 15% of the episodes may be due to Group A beta hemolytic streptococcus (GABS). Early initiation of antibiotics in pharyngitis due to GABS can prevent complications such as acute rheumatic . The drug of choice is for 10-14 days. The alternative medications include oral cephalosporins (cefaclor, cephalexin), amoxicillin or macrolides. [Indian J Pediatr 2001; 68 (12) : 1135-1138]

Key words : Upper respiratory tract infections; Pharyngitis; Sinusitis; Nasopharyngitis

Acute respiratory infections are a major cause of pathogens are significant as far as severe lower respiratory morbidity and mortality in children and of particular tract infections are concerned, but the vast majority of significance in developing countries like India. Outpatient acute respiratory infection are upper respiratory, and viral attendance attributed to acute respiratory infections is as agents are the primary causal agents. In a hospital-based high as 20-40% of all outpatients and 12-35% of in study on under-five children with acute respiratory patients. 1 In a study in rural zone of Delhi with an infection, 38% were upper respiratorytract infection. Viral estimated population of 3700, the prevalence of acute etiological agent was detected in 16.6% and the viruses respiratory infection was 12.1% for the under-fives as a isolated were A and B (45.65%), parainfluenza 1 whole. 2 The overall incidence of acute respiratory and 3 (26.08%), adenovirus (19.56%) and respiratory infection in the under-fives was observed to be 2.5 syncytial (6.52%). episodes per child per year, of which, 2.2 episodes per This bring forth the fact that, majority of respiratory year per child were upper respiratory tract infections. infections on children are due to a viral etiology which do Upper respiratory tract infections including not need antibiotics for management and judicious use of nasopharyngitis, pharyngitis, tonsillitis and otitis media antibiotics is most imperative in upper respiratory tract constituted 87.5% of the total episodes of infection. Lower infections. respiratory tract infections including pneumonia and The principles of judicious use of antibiotics in upper bronchiolitis constituted the remaining 12.5%. 2 respiratory tract infections outlined below are based on In a survey of acute respiratory infection in a rural area recent reviews. of South India, the prevalence of acute respiratory Common Cold infection was 7.6 % in a total of 10,951 children below 5 years. Majority of acute respiratory infection was mild Most children have 3-8 episodes of common cold per (defined by + respiratory rate <50) only 1.7% year. 9-1~Common cold is a viral illness, the most common episodes were severe in nature (cough + respiratory rate cause being rhinovirus; others being parainfluenza, >50 + chest indrawing/inability to drink). 3 respiratory syncytial, corona virus, adenovirus, echovirus, Thus, acute respiratory infection constitutes a coxsackievirus and parainfluenza virus, n Rhinovirus significant problem in childhood and the majority of these accounts for upto 60% of infections. 12 The etiological infections are upper respiratory infection. Bacterial agents vary with host age, and time of the year. Symptoms include nasal discharge, nasal obstruction, and Reprint requests : Dr. S.K. Kabra, Department of Pediatrics, Div. of throat irritation. Associated with this there usually is low- Pediatric Pulmonolog~ AIIMS, New Delhi-110029. grade fever, malaise, sneezing and nasal secretions can E-mail : [email protected]

Indian Journal of Pediatrics, Volume 68---December, 2001 1135 N. Jain R. Lodha and S.K. Kabra become purulent. Symptoms are non-specific and not of common cold. n Even in uncomplicated viral upper characteristic for any agent. The usual duration of respiratory infection, as occurs in common cold, there is symptoms is about 7 days. inflammation and congestion of both the nasal and the Common cold in children resolves on its own and no sinus mucosa. These infections should, therefore, be specific therapy is indicated in majority of cases. Use of considered as rhinosinusitis. 19 This inflammation antibiotics does not change either the course or the undergoes a spontaneous resolution in vast majority of outcome. 6 On the contrary use is potentially cases. About 0.5 to10 percent of upper respiratory harmful, because it increases the risk of colonization with infections are complicated by development of acute resistant organisms. This may result in subsequent sinusitis. TM Since only a small percentage of children with bacterial infection being unresponsive to standard symptoms of rhinosinusitis have a bacterial etiology, the antibiotics. 13 use of appropriate diagnostic criteria is essential, as this Common cold almost always has an excellent outcome will avoid the overuse of antibiotics. This is all the more with complete recovery, but at times complications can important because viral rhinosinusitis is 20 -200 times occur. These include acute otitis media with effusion, more common than bacterial sinusitis. 7 tonsillitis, sinusitis, and lower respiratory tract infection.'~ Sinusitis is classified as per the duration of symptoms Unless specific diagnostic criteria for the diagnosis of into acute (upto 3 weeks), subacute (3-10 weeks), and these complications are met, antibiotics should not be chronic (>10 weeks). used for the signs and symptoms of cold alone? Studies Sinusitis is almost always precipitated when a viral have shown that use of antibiotics for the prevention of upper respiratory infection produces mucosal bacterial complication of common cold has no use. A inflammation leading to obstruction of the sinus ostia. meta-analysis of five randomized clinical trials of efficacy This in turn leads to fluid trapping in the sinus cavities of antimicrobial treatment of cold to prevent lower and the normal upper respiratory bacterial flora respiratory infection found that it had no protective effect. proliferates. The most common organisms causing It also did not shorten the duration of the upper sinusitis are S. pneumoniae, H. influenzae, M. catarrhalis, S. respiratory illness. 14 aureus and S. pyogenesJ ~ But it must be emphasized that Recognizing the signs and symptoms of the usual majority of rhinosinusitis is viral and therefore, course of common cold will help to prevent the over- approximately 60% resolve spontaneously without prescription of antibiotics. Unfamiliarity with them can antimicrobial therapy. 2~ lead to the mistaken diagnosis of secondary bacterial The major problem in the diagnosis of sinusitis in infection and the inappropriate use of antibiotics. children is to distinguish simple upper respiratory tract Mucopurulent nasal dicharge, which is thick, opaque viral infections and allergic inflammation from bacterial at times greenish or yellowish frequently accompanies infection of the sinuses. The signs and symptoms in older common cold. n Antimicrobial treatment is not indicated children can be classical i.e. sinus tenderness, tooth pain, for such a discharge unless it persists for more than 10-14 headache, and high fever. However, in young children days. 6 these classical sign and symptoms are almost never In a study on 142 children with mucopurulent present. Persistence of signs and symptoms of upper nasopharyngitis, a comparison of cephalexin treatment respiratory infection i.e. or cough for more with placebo was done. Five to six days after initiation of than 10-14 days is a pointer towards sinusitis. The treatment, cephalexin and placebo groups did not differ rhinorrhea mostly is purulent but can be serous or watery. in the presence of nasal discharge, incidence of Thus, the character of the discharge is not helpful in complications, or parental opinion of benefit of distinguishing infected sinus fluid, from uninfected medicationY fluid. 21 Other indicators of sinusitis are the presence of Cough occurs in 60-80% of common cold and does not severe signs and symptoms during an episode of upper suggest a bacterial etiology.TM Duration of symptoms is respiratory infection. These include high fever > 39 ~C, usually 2-7 days. Patients usually improve within 10 days, persistent fever, periorbital swelling and facial pain. but at times cough and nasal discharge can persist for 2 Diagnosis of sinusitis is clinical and rarely are weeks or moreY investigations warranted. Radiographic evaluations are To summarize 1. Antibiotics should not be given for indicated when episodes of sinusitis are recurrent, when common cold. 2. Mucopurulent nasal discharge is feature complications are suspected or when the diagnosis is not of common cold and is alone not an indication of clear. 7 The plain radiograph shows air fluid level, antibiotics unless it persists for more than 10-14 days. opacification, or mucosal thickeningY CT scan or MRI can be done for a more detailed examination and show the Sinusitis same findings. These features can also be present in viral Sinusitis is defined as inflammation of the mucosal lining rhinosinusitis and therefore, X-ray should only be done of one or more of the paranasal sinusesY It can occur when indicated. In a study evaluating CT findings in 31 from infection or non-infectious (allergic) causes. In adults during first 48-96 hours of uncomplicated viral children sinusitis almost always occurs as a complication respiratory illnesses, 90% had abnormality of the

1136 Indian Joumal of Pediatrics, Volume 68~December, 2001 Upper Respiratory Tract Infection maxillary sinus cavity. After two week these findings is certain. This will prevent the unnecessary overuse of resolved in 79% even though none received any antibiotics. antibiotics? 9When the child is younger than six months of Symptoms of sore throat accompany pharyngitis but age, opacification of the ethmoid air cells is normal. When its presence alone should not be used for diagnosis as the child is under the age of one year, opacification or these complain can be present even in common cold. The thickening of the mucosa of the maxillary sinusitis may be objective evidence of inflammation in the form of normal. 11 This should be kept in mind when evaluating X- erythema, exudate or ulceration in the pharynx is ray findings. necessary for the diagnosis. But, these signs can also be The primary treatment of sinusitis is antibiotics once present in some viral infections like adenovirus or the diagnostic criteria have been met. Amoxycillin (40 enterovirus. mg/kg/day) is successfiJ1 for the initial treatment of acute The classical features of Group A streptococcal uncomplicated sinusitis in most children.2~ About 35% of pharyngitis include acute onset of pharyngeal pain, nontypable H. influenzae and 85% of M. catarrhalis strains dysphagia and fever. Rhinorrhea, cough, hoarseness, produce beta-lactamases and are resistant to amoxicillin. 21 conjunctivitis and diarrhea suggest a viral etiology. Therefore, if there is no response within 48 hours a Presence of patchy exudate on the posterior pharynx, beta-lactamase-stable antibiotic like amoxycillin- palatal petechie and enlarged and tender anterior cervical clavulanate or cephalexin or cetactor should be lymph nodes favour Group A streptococci pharyngitis. considered. These drugs should be considered first line if But in an individual child the clinical distinction between sinusitis is recurrent, fails to improve, or is a severe streptococcal pharyngitis and viral pharyngitis is infection with high fever and facial swelling. The duration unreliable. Therefore, in all cases of acute pharyngitis, of therapy should be minimum of 10 days.22 streptococcal disease must be considered. To summarize, 1. Diagnosis of sinusitis should be Diagnosis of Group A streptococcal pharyngitis should made when symptoms of nonspecific upper respiratory be based on throat swab culture, which is the standard for infection are present for more than 10-14.days or there are diagnosis. Antigen-detection tests alone can miss some severe upper respiratory signs and symptoms in the form cases; therefore the recommendation is to do a culture if of facial pain, facial swelling and high fever. 2. Since antigen-detection test is negative in a child with suspected radiological evidence of sinusitis may be seen even in streptococcal pharyngitis.26 Furthermore, if antibiotics common cold, radiographs should be interpreted with have been started in a child with suspected streptococcal caution and done when indicated. 3. Antimicrobial for pharyngitis and subsequently, the cultures are negative sinusitis should be narrow spectrum against the likely the treating physician should inform the parents to stop pathogen. the antibiotic therapy. Some studies have shown that early initiation of antibiotic on clinical suspicion can result Pharyngitis in decreased desirable antibody response, thus allowing Pharyngitis is an inflammatory illness of the mucous reinfection with type specific organisms.27 membranes and underlying structures of the throat. The Bacteria other than Group A streptococci are rare clinical diagnostic category includes tonsillitis, causes of pharyngitis. Moreover, sequelae such as acute tonsillopharyngitis and nasopharyngitis. Pharyngitis is rheumatic fever do not occur. Also, as already stated most subdivided into two categories: illness with nasal pharyngitis in children is viral in etiology. Therefore, symptomatology (nasopharyngitis) and illness without antibiotics should not be given to a child with pharyngitis nasal involvement (pharyngitis or tonsillopharyngitis). in the absence of diagnosed Group A streptococcal Nasopharyngitis nearly always is a viral etiology, whereas pharyngitis or other bacterial infection. pharyngitis without nasal signs has diverse etiologic The recommendation is to use 10-day course of possibilities including bacteria, viruses, fungi and other penicillin for the treatment of Group A streptococcal infectious agents. Adenoviruses are the most common pharyngitis. This is because it has a narrow spectrum of cause of nasopharyngitis, other viruses being influenza, activity, low cost and high efficacy. Group A streptococcal parainfluenza and enteroviruses. The bacterial agents resistance to macrolide antibiotics has been observed, causing pharyngitis include Streptococcus pyogenes, H. whereas, resistance to beta-lactam antibiotics has not been influenzae, C. diphtheriae, and N. meningitides. 23 detected to date. Resistance to macrolides like Group A streptococci accounts for approximately 15% azithromycin or clarithromycin would be similar to that of bacterial pharyngitis and about 1-2 patients out of 10 for erythromycin. A meta-analysis of 19 studies favoured with sore throat. Infection in most of the others is cephalosporins over penicillin in terms of higher attributable to viruses, u Early diagnosis and treatment of eradication of GABS from oropharynx.28,29 These agents Group A streptococcal pharyngitis is important, as have a wide spectrum of activity against bacteria and thus antibiotics initiated with nine days of onset are effective in encourage the emergence of resistance over a broad range preventing acute rheumatic feverY But since most sore of bacterial pathogens. Alternative treatments must be throats are viral in etiology antibiotic have to be given used in patients with penicillin , compliance issues only when diagnosis of Group A streptococcal pharyngitis or penicillin treatment failure. Patients who do not

Indian Journal of Pediatrics, Volume 68--December, 2001 1137 N. Jain R. Lodha and S.K. Kabra respond to initial treatment should be given an 13. Horn ME, Brain E, Gregg Iet al. Respiratory viral infection in antimicrobial that is not inactivated by penicillinase- childhood. A survey in general practice, Rohanpton. 1967- 1972. J Hyg 1975; 74 : 157-168. producing organisms (e.g., amoxycillin-clavulanate 14. Gadomski AM. Potential intervention for preventing potassium, cefaclor, cephalexin or a macrolides). pneumonia among young children : lack of effect of antibiotic To summarize 1. Group A streptococcal pharyngitis treatment for upper resiratory infections. Pediatr Infect Dis ] should be diagnosed using laboratory tests with clinical 1993; 12 : 115-120. and epidemiological findings. 2. Antibiotics should be 15. Todd JK, Todd N, Damato Jet al. Bacteriology and treatment of purulent nasopharyngitis: a double blind, placebo given to a child with pharyngitis only when Group A controlled evaluation. Pediatr Infect Dis J 1984; 3 : 226-232. streptococcal or other bacterial infection has been 16. Jackson GG, Dowling HF, Huldoon RL. Present concepts of identified. 3. Penicillin is the drug of choice for Group A the common cold. Am J Public Health 1962; 52 : 940-945. streptococcal pharyngitis. 17. Cloutier MM. The coughing child. Etiology and treatment of a common symptom. Postgrad Med 1983; 73 : 169-175. REFERENCES 18. Cherry JD, Newman A. Sinusitis. In Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 4th edn. WB 1. Manmohan, Bhargava SK. Acute respiratory infection. Indian Saunders, Philadelphia, PA. 1998; 183-192. Pediatr 1984; 211-213. 19. Gwaltney J, Phillips C, Miller R et al. Computed tomographic 2. Chhabra P, Garg S, Mittal SK et al. Magnitude of acute study of the common cold. N Eng J Med 1994; 330 : 25-30. respiratory infection in under five. Indian Pediatr 1993; 30 : 20. Giebink GS. Childhood sinusitis; pathophysiology, diagnosis 1315-1319. and treatment. Pediatr Infect Dis J 1994; 13 : $55-$65. 3. Tambe MP, Sivaraman C, Chandrashekhar Y. Acute 21. Doern GV. Resistance among problem respiratory pathogens respiratory infection in Children-a survey in the rural in pediatrics. Pediatr Infect Dis J 1995; 104 : 462-463. community. Indian J Med Science 1999; 53 : 249-253. 22. Wald E. Sinusitis in children. N Eng J Med 1992; 326 : 319-323. 4. Jain A, Pande PK, Mishra A et al. An Indian hospital study of 23. Cherry JD. Pharyngitis (Pharyngitis, tonsillitis, tonsillopharyn- viral causes of acute respiratory infections in children. J Med girls, and nasopharyngitis). In Feigin RD, Cherry JD, eds. Text- Microbiol 1991; 35 : 219-223. Book of Pediatric Infectious Diseases. 4th edn. WB Saunders, Phil- 5. Dowell SF, Schartz B. Resistant pneumococci: protecting adelphia, PA. t998; 148-156. patients through judicious antibiotic use. Am Faro Physician. 24. Tanz RR, Shulman ST. Diagnosis and treatment of Group A 1997; 15 : 1647-1654. streptococcal pharyngitis. Semin Pediatr Infect Dis 1995; 6 : 69- 6. Rosestein N, Phillips WR, Gerber MA et al. The common cold- 78. principles of judicious use of antimicrobial agents. Pediatrics 25. Rammelkamp CH. Rheumatic heart disease-a challenge. 1998; 101(Suppl) : 181-184. Circulation 1958; 17 : 842-851. 7. Dowell SF, Marcy M, Phillips WR et al. Principles of judicious 26. American Academy of Pediatrics. Group A streptococcal use of antimicrobial agents for pediatric upper respiratory infections. In Peter G, ed. 1997 Red Book Report of The infections. Pediatrics 1998; 101 (Suppl) : 163-165. Committee on Infectious Diseases. 24th edn. Elk Grove Village, IL 8. O'Brien KL, Dowell SF, Scharwtz B et al. Acute sinusitis- : American Academy of Pediatrics, 1997 : 83-94. principles of judicious use of antimicrobial agents. Pediatrics 27. Pichichero ME, Disney FA, Green JL et al. Adverse and 1998; 101 (Suppl) : 174-177. beneficial effects of immediate treatment of group A-beta- 9. Schwartz B, Marcy SM, Phillips WR et al. Pharyngitis- hemolytic streptococcal pharyngitis with penicillin. Pediatr Principles of judicious use of antimicrobial agents. Pediatrics Infect Dis 1987; 6 : 635-643. 1998; 101 (Suppl) : 171-174. 28. Pichichero ME, Margolis PA. Comparison of cephalosporin 10. Wald ER, Dashefsky B, Byers C et al. Frequency and severity and in the treatment of group A beta-hemolytic of infections in daycare. J Pediatr 1988; 112 : 540-546. streptococcal pharyngitis: a metaanylysis supporting the 11. Turner TB. The epidemiology, pathogenesis, and treatment of concept of microbial copathogenicity. Pediatr Infect Dis J 1991; the common cold. Semin Pediatr Infect Dis 1995; 6 : 57-61. 10 : 275-281. 12. MI Ashes. Infections of the upper respiratory tract. In Taussig 29. Jacobs RF. Judicious use of antibiotics for common pediatric LM, Landau LI, eds. Pediatric Respiratory Medicine. Mosby Inc respiratory infections. Pediatr Infect Dis J 2000; 19 : 938-943. Missouri 1999; 530-547.

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